Not all people who use a substance will misuse it, or have problematic substance use. Substance misuse occurs when a person is using alcohol or other drugs at levels that are associated with short or long-term harm. Substance misuse is not just a matter of how much of a substance a person uses, but how their use affects their lives and those around them. This includes:

Dependence syndrome

This is where a person using drugs or alcohol has become physically or psychologically dependent on using them. To be diagnosed with dependence syndrome the person will need to have experienced THREE or more of the following during the previous year.

• Craving.
• Difficulties in controlling substance use.
• Withdrawal Symptoms.
• Tolerance.
• Neglect of previously enjoyed interests.

Alcohol and drugs may cause acute states of negative or poor mental health due to their direct actions, including forms of substance induced psychosis.

Alcohol

Alcohol makes people less alert and is a depressant drug and interferes with the central nervous system. Some people use alcohol to reduce anxiety and other symptoms of mental ill health. Heavy alcohol use increases the risk of depression, anxiety and can often interfere with sleep patterns, therefore increases fatigue which contributes to depression. There are both short-term and long-term problems associated with alcohol misuse, the three main ones in each category are:

Short term problems:

• Aggression and anti-social behaviour
• Physical injuries i.e.: traffic injuries/ deaths
• Poor motor coordination i.e.: slurred speech, staggering, unconsciousness

Long term problems:

• Physical Health Problems
• Depression & Anxiety
• Psychosis

Drugs

Drugs have an effect on the nervous system and mental function, which may be sedative or hallucinogenic. As with alcohol, some people use illegal drugs to try and gain relief from symptoms of depression or other mental health issues. Types of drugs include:

• Cannabis     
• Opioid Drugs
• Prescription drugs
• Cocaine
• Amphetamines
• Hallucinogens
• Ecstasy
• Inhalants
• Caffeine

ACTION PLAN FOR SUBSTANCE MISUSE - Approach the person, assess and assist with any crisis.

If you are concerned about someone’s substance use, talk to the person about it openly and honestly. Before speaking with the person, reflect on their situation, organise your thoughts and decide what you want to say. Talk with them in a quiet private environment, at a time when there will be no interruptions and are both calm. Express your concerns non-judgementally. Consider the following:

• The person's own perception of their substance abuse
• Do they feel it is a problem?
• How much are they using?
• The person's readiness to talk

Ask about the areas of their life they think it could be affecting. Their Mood? Home Life? Work? Be aware they may deny or may not recognise that their substance abuse is problematic. Use “I” Statements i.e.: “I am concerned about how much you are drinking lately”. Rather than; “You are drinking too much lately.” Rate the act not the person. i.e.: “Your drug use seems to be getting in the way of your friendships/job,” etc., rather than “You are a pathetic druggie.” Stick to the point, focus on the person's substance use and don’t get drawn into arguments or discussions about other issues. When having a conversation with the person around how their substance use impacts on their life, you may wish to explore what type of substances they use. How often they use them and how it impacts on them and their families. Do they perceive their misuse as problematic? And whether they actively want to make a change in their behaviour. Try to have an open-ended conversation that allows the person to explore the issues at hand.

FIRST AID FOR AGGRESSIVE BEHAVIOUR ALIGNED WITH DRUG OR ALCOHOL USE.

There is an increased risk of aggression towards others for people who misuse substances. It may be verbally (threats and insults), or behaviour (hitting you, objects or walls, throwing things etc).

ACTION 1 – Assist and de-escalation.

Try to de-escalate any violent or aggressive situation by:

• Remaining calm.
• Speaking slowly and confidently, with a gentle tone.
• Don’t respond in a hostile or challenging way.
• Don’t argue with them.
• Offer them a seat if they are standing, people find it much harder to become violent if they are sitting down.
• Avoid raising your voice or talking too fast.
• Be aware that the person may overreact to negative words, so therefore use positive words instead.
• Respect their personal space.
• Consider taking a break from the conversation to allow the person to calm down.

ACTION 2 - Listen and communicate non-judgementally

• Treat the person with respect and dignity
• Be supportive when listening without making judgements
• Avoid expressing moral judgements
• Do not criticise the person's substance abuse
• Do not express frustration

ACTION 3 - Give support and information

Ask the person if they would like information about substance misuse. Try to find out if the person wants help to change their substance use. If they do, offer your help and discuss what you are willing to do. Have the phone number for alcohol and other drug helplines. However, be aware that the person will not change their behaviour or thinking towards their misuse straight-away. A person’s willpower and resolve is not always enough to help them stop problematic substance use, and they may have tried to stop previously. If abstinence from substances is not the personal goal, reducing the quantity used is still worthwhile.

Supporting the person who does not want to change

If a person does not want to reduce or stop their substance use, you cannot make them change. It is important that you maintain a good relationship with the person. Let the person know you are available to talk to in the future. You can talk to a professional who specialises in substance misuse to determine how best to approach the person about your concerns, or you could talk to others who have dealt with such difficulties about effective ways to help the person. It is also vital to look for support yourself especially if you are directly impacted by the negative consequences of someone’s substance use.

What is NOT supportive. 

If the person is unwilling to change their substance misuse, don’t:

• Feel guilty or responsible
• Use negative approaches. (e.g. Lecturing or making them feel guilty)
• Try to control the person by bribing, nagging, threatening or crying
• Make excuses for the person or cover up their substance use or related behaviour
• Take on the person’s responsibilities except if not doing so would cause harm

If the person is unwilling to seek professional help you should set boundaries around what behaviour you are willing or not willing to accept.

ACTION 4 - Encourage the person to get appropriate professional help.

Discuss the options for seeking professional help. Tell the person you will support them in getting professional help. Give them information about local support groups, charities and support options, and encourage them to make an appointment. Treatments for substance misuse will depend on the nature and severity of the problem, as well as how motivated the person is to change and what other physical and mental health issues they also have. Treatment may need to do several things:

• Overcome any physiological dependence on alcohol or drugs
• Overcome any psychological dependence (use of alcohol or drugs to help the person cope with anxiety or depression)
• Overcome habits that have been formed (social life that revolves around drinking or drug use).

There are a variety of health professionals that can provide support to a person who is misusing substances. If the person is uncertain about what to do, encourage them to consult their GP. Their GP might refer the person to a drug tor alcohol service, or to a mental health professional. The following treatments are known to be effective and recommended by National Institute for Health and Care Excellence (NICE) guidelines. These are intended as a guide to what kind of treatment can be expected under best practice guidelines in England. They are not intended for the Mental Health First Aider to suggest as treatments in a specific case, but may be helpful to understand what treatments may be offered when the person seeks professional help.

1. GP's Brief Intervention can be used in a wide variety of settings and may be especially helpful for people not yet in contact with specialist drug or alcohol services. Brief intervention can help motivate the person into long-term treatment.
2. Psychological Treatments - Cognitive Behavioural Therapy teaches how to recognise and cope with cravings, and cope with situations that might trigger relapse.
3. Behavioural Therapy - teaches the person to change behaviours related to drug or alcohol use.

ACTION 5 – Support and Support Groups

Family, friends and support groups can play an important part in the recovery of a person misusing substances. People are more likely to recover if: 

• They have stable family relationships.
• They are not treated with criticism and hostility by their friends or family.
• They have supportive friends.
• Their friends don’t use alcohol or drugs themselves.
• They can interact with people who have, or are going through the same difficulties and challenges.